Download Abdominal Pain Abdominal Pain

Abdominal Pain
Melissa Kerg MD
Howard Werman MD
Abdominal Pain
· Can be a challenge to diagnose
· Personal biases
· Presumptive diagnosis hastily made
· Inefficient use of time and tests
· Delay in making actual diagnosis
· Mortality doubles with incorrect
diagnosis
1
Introduction
· 10% of all undifferentiated patients
presenting to ED have abdominal pain as
a major complaint
· missed appendicitis and missed
abdominal aortic aneurysm are among
the leading causes of malpractice actions
Abdominal Pain
· Pain
· Subjective
· No objective measures of pain
· Vital signs without sensitivity or specificity
· Pain Scales
· Ask the patient
· Useful to tract progress of treatment
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Treat the Pain
· Goal is pain control not pain relief, there
is a difference!
· Patients are very receptive to being told
that we want to lessen the pain and make
it tolerable but that its not realistic to
remove it completely.
Abdominal Pain
· It can be anything from the nipples to the
pelvis
· Abdominal pain may not be associated
with disease processes in the abdomen
· Abdominal pain may be associated with
disease processes not in the abdomen
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Abdominal Pain
· At least 5-10% of ED visits
· Up to 50% remain undiagnosed at
discharge
· 5-10% of these have significant disease
· Small % of admitted patients are
misdiagnosed
· Delays treatment
· Added morbidity and mortality
Goals
· to identify any immediate lifethreatening causes of abdominal pain
· 15-30% of patients require immediate
surgery
· to make an educated guess as to
underlying medical condition
· most common dx: nonspecific abdominal
pain (40-60% patients)
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General Approach
· Rule out surgical pathology
· Look for non-surgical causes
· Referred pain
· Systemic illness
· Gut feelings are important and develop
over a career
Causes of Abdominal Pain
within the Chest
· Angina/MI
· Pleuritic irritation
· Great vessels
· Aortic dissection
· Aortic aneurysm
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Causes of Abdominal Pain
Abdomen/Pelvic Organs
·
Stomach
·
Intestines
Gastritis, PUD, gastroenteritis
·
Pancreas
·
Liver
·
Vessels
·
·
·
·
Ureters
·
Uterus
·
Ovaries and fallopian tubes
·
Appendicitis, SBO, diverticulitis,
incarcerated hernia, ischemic gut,
IBD
·
·
·
Pancreatitis, pseudocyst
Acute hepatitis, biliary tract disease
AAA, Renal/splenic aneurysm
Spleen: Splenic rupture
·
Colic, stones, UTI
PID, fibroids
(ruptured) ectopic, ovarian
cyst, Mittelschmerz, torsion
·
Prostate
·
Testicles and associated
structures
·
·
Prostatitis
Torsion, hydrocele,
Retroperitoneal
· Kidneys
· Pyelonephritis, infarction
· Great Vessels
· AAA
· Muscles (psoas)
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Miscellaneous
·
·
·
·
Abdominal Wall
Shingles
Hernias
Spontaneous
Bacterial Peritonitis
· Acute Intermitent
Porphyria
· Strep Throat (think
pediatrics)
· Diabetes (DKA)
· Acute narrow angle
glaucoma
· Black Widow Spider
Bite
History
· Many symptoms are neither sensitive or
specific
· Few disease processes in abdomen have
pathognomonic historical features
· The “typical appendicitis” occurs in only 33% of
cases
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But with that being said….
· Inadequate history most common feature
of leading to a misdiagnosis
History
· In assessing the patient with abdominal
pain, a careful history will lead to a
reasonable diagnosis in more than 80%
of cases
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History
· Suggestive of a surgical cause??
· Sudden onset
· Lasting 1-2 days
· Subsequent peritoneal signs
· Anorexia
History
· location: major factor in developing a
differential diagnosis
· character
· radiation
· onset/chronology
· aggrevating/alleviating factors
· associated symptoms: anorexia,
nausea, vomiting, bowel changes,
urinary sx, vaginal sx
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History
Location of the pain major factor in
developing a differential diagnosis
History
10
History
History
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History
History
·
·
·
·
·
·
O
P
Q
R
S
T
onset
palliation/provocation
quality
radiation
severity
time
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How Fast Did It Start
· Sudden onset
· Perforated ulcer, mesenteric infarction, ruptured AAA,
ruptured ectopic pregnancy, ovarian torsion, ruptured
ovarian cyst, PE, AMI, testicular torsion
· Rapid onset (minutes to hours to max)
· Strangulated hernia, volvulus, intussuception, acute
pancreatitis, biliary colic, diverticulitis, ureteral colic
How Fast Did It Start
· Gradual Onset
· Appendicitis, chronic pancreatitis, PUD,
inflammatory bowel diseases, mesenteric
adenititis, uti, urinary retention, salpingitis,
prostatitis
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History
· Where did it start?
· Migratory?
· Where is it at?
· What makes it worse or better?
· Movement, bumps, cough
· Eating
· How soon after
· Position
· Associated symptoms
History
· PMH
· Have you ever had this before??
· SH
· Alcohol
· Tobacco
· Recreational drugs
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Abdominal Pain
· There are 2 types of abdominal
pain
Abdominal Pain
· Visceral
Foregut, midgut, hindgut
· Autonomic nerves
· Innervates involuntary
muscles, heart and
glands
·
·
·
·
Poorly localized
Achy/colicky
Intermittent
Felt in the abdominal
wall in the area of
embryonic origin of the
pain
· Somatic
· Typical pain and
temperature fibers that
innervate the skin
· Irritation of the parietal
peritoneum or mesenteric
root
· Intense and well localized
· Sharp
· Felt directly over area of
inflammation
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Abdominal Pain
· A 20 yo female OSU student presents with
sharp RLQ abdominal pain. The patient
reports that the pain began approximately 6
hours previously as a dull periumbilical
pain which suddenly became localized 30
minutes ago. Can you explain?
Abdominal Pain
· Referred pain: pain felt at a site distant
from the involved abdominal organ due to
a shared cutaneous sensory nerve
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Abdominal Pain
Vital Signs
· Vital signs
· Orthostatics---when would they not be useful?
· Fever
· When is it unreliable?
· Heart Rate
· Intra-peritoneal blood may be associated with a relative
bradycardia (ectopics)
· Medications
· Respiratory Rate
· Vital signs do not correlate well with patients level
of pain
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Physical Examination
· General Appearance
· May the most useful
· HEENT
· Cardiac
· Pulmonary
· Abdominal
· Rectal
· What will cause
black, but heme
negative stools?
· GU
· Check for hernias,
especially in the
pediatric population
Physical Examination
· Observation
· “What do I see?” Look as you enter.
·
·
·
·
·
·
·
Level of comfort
Position
Still vs active
Diaphoresis
Breathing pattern
Distention
Icterus
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Physical Examination
· Auscultation-prior to palpation
· Bowel sounds
· Poor predictor of peritonitis
· People with peritonitis do have bowel sounds!!
· Listen for minutes-not practical in the ER
· rushes
· Bruits
Physical Examination
· Palpation
· Masses, organomegaly
· If you don’t think to check for it you will not find it
· Tenderness
· Abdominal pain with coughing or heal strike more sensitive than
palpation or Rovsing’s
· Guarding
· Voluntary
· Involuntary
· Unilateral always involuntary
· 25% of patients with rebound tenderness do not have surgical
pathology
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Physical Examination
· Hernia
· Ventral, inguinal, femoral, umbilical
· Rectal
· Pelvic
· Carnett’s Test
· Straight leg raise or have patient lift head and
tightened abdominal muscles and palpate
· If the pain increases - abdominal wall
Rectal Examination
· Only useful to check guaiac or for local
phenomena (perirectal abscess)
· Will not/can not help with the diagnosis
of appendicitis/diverticulitis
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Signs
· Carnett’s
· Murphy’s
· 50% specific (less in elderly)
· Presence or absence should not preclude diagnosis
· Ultrasonic (radiographic) murphy’s sign
· Psoas
· Not specific but sensitive
· Obturators and Rovsing’s
· Not predictive of anything good or bad
What are we trying to
diagnosis?
· Bad stuff!!
·
·
·
·
·
·
Ruptured viscus’
AAA
Ischemic bowel
Appendicitis
Strangulated hernia
Ectopic pregnancy
·
·
·
·
·
Gallbladder disease
Pancreatitis
Bowel obstruction
PID
Torsions
· Need to go to OR!
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The Rest
· Could be the early presentation of more
serious disease
· Usually nonspecific self limiting diseases
· Follow up is going to be important
Diagnostic Approach
· Prior to ordering any tests you should
have a reasonably short differential to act
on
· In a significant minority of patients with
abdominal pain, no tests are needed other
than a u/a (and pregnancy test in females)
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The Tests
·
·
·
·
What is needed?
We over-utilize every test we can
CBC, AAS, Amylase, LFT’s
Pregnancy Tests may be under-utilized
But….
· Always consider an ECG on patients
with upper abdominal pain or nonspecific symptoms in their coronary
years
· Consider a Chest x-ray on young
children
· Consider glucose testing (DKA)
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Blood
· WBC
· Not sensitive, not specific, not predictive
· Can be misleading
· Amylase
· Not specific, > 3 times upper level of normal
· Lipase
· More specific and sensitive
· Rises as quickly as the amylase but stays elevated 2x
longer
Blood
· LFT’s
· Abnormal in only 50% of acute cholecytitis
· Just a ALT and urine bilirubin to screen for hepatitis
· Full battery if patient icteric
· Chem 7
· Why??? Only needed for protracted vomiting or
dehydration. BUN/Creatinine is needed prior to IV
contrast
· Lactate-late finding
· Type and screen vs type and cross
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Urinalysis
· Up to 33% of patients with appendicitis
have blood or WBC’s in the urine
· 50% with ruptured appy have wbc’s
· 33-67% of AAA have blood in their
urine
· Urine pregnancy
Radiology
· AAS
· No role in undifferentiated abd pain
· Obstruction, perforation, or foreign body
· The patient needs to be upright for 10 minutes to
increase sensitivity
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Radiology
· Ultrasound
· Not useful in undifferentiated abd pain
· Wonderful for directed exams
· Screening exam for most diagnoses by EP
· Sensitive for AAA but not for dissection
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Radiology
· CT scan
· Know what you are looking for
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Special Considerations
· Elderly
· Higher prevalence of disease
·
·
·
·
·
·
Up to 40% require surgery
Majority have co-morbid illnesses
Longer delay to presentations (2X)
Less likely to have a fever
Higher morbidity and mortality
Higher atypical cholecystitis incidence
Special Considerations
· Steroids
· Blunt inflammatory response
· No peritonitis possible
· Children
· Transfer to a higher level of care if you are not
comfortable with children, especially the infants
· Intussusception
· Typical: male, 5-10 months old, involves
ileocecal valve
· Colicy pain, bloody stool or mucus within
several hours
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The Most Common Causes of
Children Presenting with Acute
Abdominal Pain
·
·
·
·
URI/OM 18.6%
Pharyngitis 16.6%
Viral Syndrome 16%
Abdominal Pain ?
Etiology 15.6%
· Gastroenteritis
10.9%
· Acute Febrile Illness
7.8%
· Bronchitis/Asthma
2.6%
· Pneumonia 2.3%
· Constipation 2.0%
· UTI 1.6%
· Appendicitis 0.9%
Gastroenteritis
· Vomiting (Gastro) and diarrhea
(enteritis)
· Frequently used as diagnosis
· Appendicitis malpractice issue
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It’s not simple
· Frustrating to patient, family, staff and
you at times
· Don’t forget repeat exams
· If ever in doubt, obtain second opinion
· CLEAR discharge instructions
· Problem could not be identified
· Repeat evaluation in 8 - 12 hours
· Precautions
Discharge Instructions
· write all discharge instructions in language
understandable to the patient
· avoid medical abbreviations
· carefully describe any therapies prescribed
· identify clear follow-up for each patient
· list the signs and symptoms for which the
patient should immediately return for
evaluation
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Cases
· 35 y/o female with upper abdominal pain
·
·
·
·
·
·
·
Vitals: Temp 97.5, BP 122/70, HR 92, RR 18
Hx: Pain, some nausea, no vomiting. Radiates to back
PHx: S/P cesarean 6 weeks ago, known gallstones
PE: RUQ tenderness, soft elsewhere
Test?
Labs?
Medications?
Continued
· WBC 14.5, LFTs normal
· Ultrasound shows:
· Gallstones, gallbladder wall is not thick, no
pericholic edema. Common bile duct is
1.5cm diameter
· Disposition of patient?
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Case 2
· 79 y/o female from ECF with Abdominal
pain
· Vitals: Temp 99.4, BP 110/66, HR 60, RR 20
· Hx: Little ostomy output today, urinated once today,
feels bloated
· PHx: Colon Ca 1999 s/p partial colectomy, SBO, UTI,
Mild dementia, Renal insufficiency, HTN
· PE: Diffuse tenderness, worse in the RLQ, mild
distention. Rectal: no stool. Thin liquid in ostomy bag
Case 2
·
·
·
·
Labs?
X-rays?
Medications?
Differential diagnosis?
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Case 2
· WBC 19.9
· BUN 43, Creatinine 2.7 (baseline 1.6)
· AAS: Mildly dilated small bowel,
possible ileus vs. PSBO
· What is the next step?
Case 2
· CT without IV contrast:
· Diverticulitis of the right colon
· Disposition?
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Case 3
· 82 y/o male with left side pain
· Vitals: Temp 98.5, BP 188/110, HR 105, RR 22
· Hx: Intermittent sharp pain, hurts to the back, no pain
now
· PHx: Mass in the abdomen, told to keep a watch on it
(this was 5 years ago), kidney stone >40ys ago, HTN,
CAD
· PE: RRR, CTA, Abd soft, NT, pulsatile mass midline,
pulses equal
Case 3
·
·
·
·
Differential Diagnosis?
Labs?
Medications?
X-rays?
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Case 3
·
·
·
·
WBC nl, Hgb 10.8
PT/PTT nl
UA: 1+ blood
BUN and Creatinine of 30 and 3.0
· Diagnostic dilemma?
· Disposition?
Case 3
· Follow up: Pt was admitted with BP
control.
· Surgical repair of 7cm AAA performed,
however pt died of post-op complications.
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Case 4
· 13 y/o girl arrives 6:30Am with RLQ pain
·
·
·
·
·
·
Mom talks 99% fo the time
Vitals: All normal
Hx: Similar pains in the past, never lasting more than 1 hour at a
time. This time non-stop since 8PM. Sharp pain, sudden onset.
Now has N/V
PHs: Menarche 11 y/o, never regular; never had a pelvic before.
Soc: Never sexually active, Started OCPs 4 days ago by PMD to
help regulate her cycle and stop the pains.
PE: Flat abd, slender, keeps knees and hips flexed. Severely tender
in RLQ and suprapubic areas (pelvic deferred until pain meds)
Case 4
·
·
·
·
Differential Diagnosis?
Labs?
Medications?
X-rays?
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Case 4
· After pain meds and antiemetics…pelvic reveals pain and fullness
of the right adnexa
· Pregnancy test is negative, WBC 17
· Differential diagnosis further narrowed?
Case 4
Ultrasound: right ovarian torsion
· Pt went to surgery and the ovary was saved
· Pt had numerous cysts
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Case 5
· 44 y/o male complains of abd pain
· Vitals: Temp 99.2, BP 90/66, HR 120, RR 28
· Hx: Sharp, constant pain epigastic area, some N/V
· PHx: Similar pain in the past, never this intense, told of
elevated BR in the past
· Soc: Drinks significant ETOH whenever possible,
homeless
· PE: Dry mouth, tachy, CTA, scaphoid abdomen, tender
in the epigastric area
Case 5
·
·
·
·
Differential diagnosis?
Labs?
Meds?
X-rays?
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Case 5
·
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Rectal: little stool, heme positive
AAS: no free air
WBC 14, Hgb 9
Lipase 120
LFTs: AST and Alk Phos are elevated
· Why are these elevated?
· NG: positive for dark blood….>200cc
· Management?
Summary/Conclusions
· abdominal pain is a common presenting
complaint
· goal is to identify immediately lifethreatening (surgical) problems and make an
educated guess as to other causes
· identify the ‘toxic’ patient
· the history is most important is establishing
the diagnosis
· give clear discharge instructions
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